Exploring opportunities to provide high-quality, community-based care for high-need patients

In the U.S. today, there are more than six million people aged 65 years or older living with multiple health conditions. Examples of such conditions include diabetes, heart disease and chronic obstructive pulmonary disease. Many of these "high-need" individuals are also limited in their ability to perform everyday tasks, which can include bathing, dressing and even walking. This population is also living longer. The last phase of life can be several years, with health on a slower, more extended, decline.

Over the next few decades, the age of the U.S. population will shift dramatically with people 65 years and older reaching nearly 84 million – that is almost double the population as of 2012. From a health care perspective this rapid growth, combined with an increase in health needs for a population that is living longer, will have a tremendous burden on our health care system.

One of the greatest challenges, in addition to the cost of care, is coordinating and delivering care based on individual preferences and in the places people want to receive it: in the community and in their homes. This will require building new models that integrate the currently fragmented array of primary, specialty and end-of-life care services. It will also require broadening the scope of palliative, or comfort, care programs beyond hospitals and into the home. Expanding the use of telehealth, coordinating with social services agencies and providing much needed support to the more than 42 million unpaid family caregivers are also requirements.

We see five mutually reinforcing strategies critical to the success of building, spreading and assessing community-based care programs. Derived in part from the Institute of Medicine report Dying in America, the strategies include: surveillance system; public education; payment and accountability; workforce development; and model programs.

The first strategy focuses on sector-wide surveillance to inform and guide the transition within the health care sector and to help the foundation identify opportunities for strategic investments and evaluate the impact of its investments and that of its partners. The next three strategies are environmental drivers that must be shaped to allow new community-based delivery models for high-need patients to develop and thrive. The fifth strategy is about designing, testing and scaling of model delivery programs.

The foundation plans to commit $40 million over the coming three years (2017-2019) to encourage the development of community-based serious illness programs. Recognizing that change will require the support of many, and that we cannot do it alone, we identified two areas we believe we can have the greatest impact:

  • Strengthening workforce training and support; and
  • Building effective quality measurement and accountability programs for community-based services.

We use the term “workforce” to include both paid and unpaid providers of services. Over the coming few years, we will place particular emphasis on training and support for family caregivers, who provide the bulk of “frontline” services. We also want to help home health aides, social workers and nurses acquire the requisite skills to practice in new delivery models that rely on high-functioning, inter-professional teams to provide home-based care.

From an accountability standpoint, there is an opportunity to fill a void. Currently a robust consumer protection system does not exist for community-based serious illness programs. Such a system might include: performance measures for use in public reports that help people select the best providers, payment programs that encourage and reward the provision of high-quality care, and accreditation programs for community-based serious illness programs.

Over the next three years, we look forward to collaborating with our many partners in this area and sharing our progress and what is learned along the way.

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